A Special Case Review has criticised social workers for missing the signs that the brothers were in a potentially harmful environment.

Their mother Shelly Adams will not face charges in relation to the deaths after the Crown Prosecution Service (CPS) concluded there was not enough evidence to prosecute.

The report, which savaged the services, said:

Social services leadership and management was “weak”.

Bradley was in the care of Shelly Adams when he died but was supposed to be looked after by his grandmother.

Staff did not have the knowledge or skills to work on complex cases such as this.

Southampton Children's Services was in “disarray” due to staff shortages.

Failed to recognise their mother's health issues and their impact on her parenting.

Two-year-old Jayden died on January 6, 2011, after suffering a cardiac arrest.

Initially the cause of death was treated as natural causes but a police investigation was launched after older brother Bradley, four, died just three months later.

An inquest last November said their deaths were shrouded in “considerable uncertainties” and said the boys led an appalling life under the care of their mother.

The hearing was told how she dished out “corporal punishment” to an inappropriate and excessive extent and would shout at Bradley when he was a baby just to get him to be quiet.

Home conditions were poor, Ms Adams failed to protect her sons and they didn't even get given “appropriate” food.

She had difficulties managing their behaviour, she handed out “harsh and excessive” punishment and would smack her children for simply being lively and inquisitive toddlers.

The inquest was told how evidence given to the High Court in care proceedings in 2012 showed that despite considerable support from social services, she was guilty of “serious and chronic neglect” of her children.

Then-Coroner Keith Wiseman, reading from a 40-page judgement from the care hearing, said Ms Adams was “simply unable to cope with the demands of caring for her children”.

The report confirmed “a low standard of parenting became accepted as the norm” after a lack of “decisive action” from children's social care.

But just one month before Jayden's death, Ms Adams pleaded with social services to take her children in to care but was convinced otherwise.

On one occasion she even packed their bags and announced she was sending them into care.

The report revealed concerns dated back to 2007 after Bradley was born.

A risk assessment by adult social care workers found Ms Adams should not live alone, yet was “deemed to be safe to live alone with a small baby”.

Her case was then closed shortly afterwards and when she asked for more help, she was told she should be able “to manage on her own”.

Later when Jayden was born, it was agreed he and Ms Adams would stay with her mother but within a month this was not happening, the report found.

According to the review, there was an increasing evidence of neglect within the home and there were indications Ms Adams knew she was not coping.

But despite all this poor management within children's social care saw the case eventually being closed.

When the case was reopened significant staff shortages meant Ms Adams was unable to form a trusting relationship with care workers, while social workers assigned to her case lacked experience and skill.

Health workers also failed to assess the impact of her learning disability on her role as a parent.

The report also revealed there were no pre-birth assessments carried out on Ms Adams, which was a “lost opportunity” to consider her capacity as a parent.

Mistakes:

- Shelly Adams' calls for her children to be taken in to care were dismissed.

- Social and health workers failed to adequately assess the impact of a learning disability and failure to take medication on the mother's ability to parent.

- Staffing within the Southampton Children's Service was in “disarray” due to staff shortages.

- Bradley was supposed to be in the care of his grandmother but checks were not carried out.

- The leadership and management of children's services was “weak”, and staff did not have sufficient skills and knowledge.

Lessons learned:

- Social workers should ensure face to face meetings take place rather than phone calls.

- Children's services should require regular evaluation of the quality of supervision being provided.

- Adequate access to records kept across adult and children's social services must be provided.

- All agencies should work closer together through the Multi Agency Safeguarding Hub (MASH).

- Cutting the use of agency staff and replacing them with full-time posts with smaller case loads.

Ipsoregulated

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